Cholera Chloroform and The Science of Medicine A L... - (CHAPTER 4 Forging A London Career 1838-1846)

Chapter 4
Forging a London Career,

1838–1846
I N OCTOBER 1838 John Snow “nailed up his colours” as a surgeon

at 54 Frith Street, part of the parish of St. Anne-Soho, one of Victo-
rian London’s most densely populated areas.1 A jumble of trades, shops, markets, of-
Copyright © 2003. Oxford University Press, Incorporated. All rights reserved.
fices, and residences, Snow’s new neighborhood was a mixture of the genteel and the
humble, of family and industry. Once home to foreign aristocrats and Huguenot im-
migrants, this part of Soho was by the 1830s an area in flux. At its northern end was
Soho Square, built around a central garden, with houses occupied by lawyers, den-
tists, architects, the publisher Routledge, and Crosse and Blackwell’s manufactory of
condiments. At the northwestern edge of the square was the Soho Bazaar, a closed
market originally established at the end of the Napoleonic Wars as a venue where
the widows and daughters of army officers could rent stalls cheaply by the day to
sell their handicraft, mainly jewelry, millinery, gloves, lace, and potted plants. 2 Snow
lived at the opposite end, near where Frith dead-ends into King Street.3
According to the 1841 census, 540 people resided in the 600 feet that constituted
Frith Street.4 It was a densely packed thoroughfare; on average, each house had nine
residents, and many exceeded the average by a considerable margin. Twenty-nine
people were listed in the five flats at number 19. William Searle, a fifty-five-year-old
bookbinder and his wife, Lucretia, aged forty-five, headed one household contain-
ing two adult sons and three more children ranging in ages from nine to thirteen.
Nine people shared another flat, and in yet another lived a forty-year-old woman of
81
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82 Cholera, Chloroform, and the Science of Medicine
independent means, a boy of twelve, a painter’s apprentice, and a female servant. In

the fourth flat lived a painter with his wife and their four children. The fifth con-
tained a sixty-five-year-old gold-laceman, his wife, and an unmarried daughter of
twenty-five.5 Londoners lived cheek by jowl with recent immigrants and migrants
from the country. Apprentices lived next to picture dealers and solicitors. Tailors,
embroiderers, music sellers, bookbinders, engravers, bakers, iron- and cheese-
mongers, tea merchants, and stay makers all made their home and living here. There
was also a violin and guitar maker, a language teacher, a glass enameler, a coffee
house, and a public house, the “Coach and Horses.” Young and old, day laborers and
artists, dentists and doctors all crowded into the street, but 54 Frith Street was some-
thing of a refuge from the hubbub. The 1841 census indicated that just four people
lived there: Sarah Williams[on], fifty-five and independent; her thirty-year-old
daughter, Harriet; Jane Weatherburn, a female servant, aged thirty, born outside the
county; and John Snow, surgeon, twenty-five years of age.6
Four other surgeons were located within a few doors of him—August Sannier at
56 Frith Street, George and Joseph Toynbee at 58 Frith Street, and Alexander Angus
at number 66. Peter Marshall, with whom Snow would work regularly, had premises
in Greek Street, which ran parallel to Frith. Like Snow, these were all men hustling
to make a career for themselves in the great emerging medical middle class of Lon-
don. The nearest physicians lived in Golden Square, a quarter-mile to the southwest.7
Snow’s practice for the first eight or nine years largely depended on patients from
the area in which he lived. It would not be surprising if he often questioned his de-
cision to start from scratch in a metropolis oversupplied with GPs, many of whom
were having great difficulty attracting patients.8 Consequently, there was consider-
able turnover in general, and Snow’s part of Soho was no exception. For example,
by 1841 J. L. Curtis and Co., surgeons, had set up shop at 7 Frith Street, the Toyn-
bees and Sannier were no longer listed in the city directory, and Hugh W. Diamond,
another surgeon who would go on to pioneer psychiatric photography, had moved
into number 59.9 Curtis headed a group practice, Diamond brought an apprentice
with him, Alexander Angus had an assistant, and Snow remained at 54 Frith Street
until 1852. For those who could make a go of it, there was obviously demand in this
district for general practitioners.10 Initially, at least, Snow followed custom in secur-
ing appointments as surgeon to four friendly societies, or sick clubs; 64 percent of
GPs in a sample covering the years 1820–1879 had at least one nonhospital ap-
pointment such as a friendly society.11 These voluntary associations, forerunners of
the capitation schemes of the next century, collected a few pence per week from every
laborer and paid practitioners an annual lump sum—often quite small—for treat-
ment of the workers and, sometimes, their families.12 Snow had an intense bent to-
ward research, but there were no paid positions as a medical scientist in London un-
til after midcentury. Not until the Public Health Act was passed in 1859 was there
any provision for the paid employment of “investigatory” medical staff, and even
then there were very few such positions and only on a temporary basis.13
Forging a London Career, 1838–1846 83
Before the advent of anesthesia, John Snow was largely able to make a living as a
GP in London and still have time for research and medical society meetings because
of his thrift and his energy. His modest means never exceeded his expectations.
Richardson remarks that Snow “managed by his frugality to lay in store for a rainy
day for himself, and to help such friends as needed.” A teetotaling vegan during his
first five years as a London GP and a temperate vegetarian thereafter, he was a health
enthusiast his entire adult life. He dressed plainly and remained a bachelor.14
Finding His Way, 1838–1839

Snow’s marginal success in general practice was all the more remarkable because he
evidently did not possess an easy bedside manner. The word on John Snow was: “A
quiet man, very reserved . . . not easily to be understood and very peculiar.” He
habitually spoke in a husky voice, which “rendered first hearings from him painful,”
and he sometimes had trouble making himself heard in meetings.15 When Snow did
meet with success from using anesthesia, it was widely assumed that he got rich from
milking this practice. While an obvious research talent, he was in some ways lack-
ing in humanity. In his memoir Richardson felt compelled to defend Snow from
these criticisms but readily conceded that “He did not become the idol of the peo-
ple in common practice, far from it.”16 Richardson felt that Snow’s lack of popular-
ity was a sign of his medical integrity. Richardson relates that in Snow there was too
much of the skeptic to be popular and none of the quackery or “routine malprac-
tice which the people love,” and as a poor boy from York he had no entrée to “the
bedsides of dowagers of the pill-mania dynasty.”17 Such skeptics did not become rich
by writing prescriptions or compounding medicines. Undoubtedly, he was never one
to tell people what they wanted to hear for the sake of popularity. Nonetheless, his
anesthesia casebooks indicate that he was very capable of putting nervous patients
at ease. Additional factors not addressed by Richardson include Snow’s temperance,
which likely alienated him from the heavy-drinking working clientele in his neigh-
borhood. The casebooks occasionally reveal his impatience, sometimes downright
irritability, with what he perceived as general ineptitude among his neighbors. In an
example from April 1850 that ties together his antipathy toward alcohol and his skep-
tical attitude toward the locals, Snow consulted on a case of delirium tremens. His
friend and colleague Peter Marshall asked for his assistance with a long-time alco-
holic who had been unable to sleep for two days. The man was shrieking, shaking
violently, and hallucinating when Snow was called in. His course of treatment was
basically to sedate the patient with opium and to induce ordinary sleep by way of
chloroform. The strategy seemed to be working but was undermined because the
man was, as Snow complained in his notes, “surrounded by a lot of ignorant people
who made him more excited by boisterous attempts to keep him quiet.”18 Eventu-
ally the patient was removed to St. George’s Hospital for further treatment in a more
stable setting, but Snow’s remark does suggest the distance between him and the gen-
eral public on how to behave when a medical man was in attendance. His candor
about the deleterious effects of alcohol also came between him and his patients.
On the other hand, he was immensely respected by his colleagues, and not just
the research oriented. He was an acute diagnostician in regular practice, and his col-
leagues in Soho regularly consulted him about difficult cases. Marshall was in awe
of Snow’s practical knowledge and encyclopedic knowledge. One area in which Snow
excelled was in the care and delivery of babies. His interest in midwifery, which in
his day included the study of diseases of women and children, probably began dur-
ing his apprenticeship experiences at the lying-in hospital in Newcastle and was nur-
tured during his London training by Drs. Ryan and Jewell. When Snow began pre-
senting case reports in journal articles and at medical society meetings, he often drew
on his practical expertise in obstetric, gynecological, and pediatric practice.19 Ob-
stetric work helped build up a practice, although it was time consuming, and
the regular fee for a delivery in the poorer practices was only ten shillings and six-
pence or even less,20 but it was a way in which a doctor might become the family
physician.
Having assured himself of at least a modest practice and the attendant income,
Snow proceeded to solidify and deepen his relationship with the Westminster Med-
ical Society, which he had first joined as a student.21 His career as a medical scien-
tist and his involvement with the Westminster Medical Society were closely inter-
twined. Richardson stated, “I have often heard him say, both privately and publicly,
that, upon this early connexion with the ‘Westminster Medical,’ his continuance in
London depended, and all his succeeding scientific success.”22 The Westminster Med-
ical Society had once had 1,000 members, but by the time Snow joined its fortunes
were sinking. Soon after Snow completed his studies, the Hunterian Medical School
in Great Windmill Street closed down. This was a double calamity for the West-
minster. Most of its membership had been drawn from the student body of the
school, and it had enjoyed rent-free use of the school’s facilities for meetings for
many years. It suffered a dramatic decline in membership and depleted its financial
reserves as it had to rent temporary quarters. In 1843 it reached low ebb, with only
a dozen members remaining. Snow stuck with the Westminster during its dark days
and was a faithful participant. In the first five years of his membership, he attended
more than 90 percent of the weekly meetings on Saturday evenings, taking a guest
more than a third of the time.23 Over time he was elected to various offices. For ex-
ample, he was on the advisory committee for the 1842–1843 and the 1846–1847 ses-
sions and vice-president in 1848–1849.24 Meanwhile, the society added new mem-
bers, eventually reaching 275. It continued to be dogged by financial concerns, so in
1849 the officers sought amalgamation with the like-minded Medical Society of Lon-
don, in part because the two societies had a large number of members in common.
The Medical Society of London had been founded in 1773 by Dr. John Lettsom,
a forerunner of the medical radicals who came into prominence in the 1830s. Sixty
years earlier he perceived the need for a society that would admit physicians, sur-
geons, and apothecaries on an equal footing and that would allow Quakers and Dis-
senters to be members, but after thriving for a long period, the Medical Society of
London had, like the Westminster, fallen upon hard times. An amalgamation of the
two was a natural solution, but the joint society had to take the name of the former
organization because of a technicality in the Medical Society of London’s lease on
its property.25
In the early days of Snow’s career, however, the Westminster retained a distinct
identity, and it provided him with a comfortable environment to meet most of his
professional and social needs.26 While Snow’s fondness for the Westminster was deep
and abiding, it was not exclusive. In 1843 he was elected a fellow of the Royal Med-
ical and Chirurgical Society, but, according to the society’s Transactions, he gave few
papers at this staid society of medical conservatives, and the medical press recorded
few comments by him.27 The more bellicose side of Snow, who had argued with
Hardcastle over the brandy treatment for cholera and who set out to clean up Wat-
son’s surgery without first consulting his principal, was reserved for the Westmin-
ster, where he could participate in the rough-and-ready debates without making en-
emies. Generational differences in the membership brought stark disagreements. The
older generation at the Westminster consisted mostly of men whose formal London
training involved far fewer courses than Snow was required to take, occurred at a
time when Cullen and Brown were considered “modern” theorists, and preceded the
wave of Continental ideas and foreign influences that transformed medical school-
ing in the 1830s.28 The newer generation, by contrast, either had the social advan-
tages necessary to travel to the Continent for additional training or became aware
of the newer work in hospital and laboratory medicine through journals.29 Snow
shaped his nascent career by allying himself with the new generation and (as politely
as possible) lecturing to the older generation to insist that the hospital and labora-
tory approaches received a fair hearing. Because the norm for research, especially
laboratory research, at that time was still solo investigation, Snow indicated his al-
legiance to the new generation primarily by citing the same authorities and refer-
ring to the same published works.
This generational divide and Snow’s position in it was evident in the early papers
he delivered at the Westminster. On Saturday, 7 December 1839, he read a lengthy
account of twelve cases of scarlet fever that had been followed by severe edema, with
four deaths. His conclusion was that “disorganization of the kidney might be occa-
sioned by scarlet fever.”30 The context for his discussion of these cases was recent
medical research, not empirical medicine. His review of the literature featured the
discovery by Dr. Richard Bright of the relationship between albumin in the urine
and certain diseases of the kidney.31 Then he showed how Bright’s findings could ex-
plain the cases he had treated. The first was a girl aged twelve whose severe form of
scarlet fever was followed by a generalized swelling involving the chest and abdomen,
eventually leading to death. His postmortem examination—Snow laid the specimens
before the society—showed that her kidneys were grossly enlarged. In two of the
other deaths the kidneys were found to be much congested postmortem, the lungs
were edematous, and there was pericarditis (inflammation of the membrane sur-
rounding the heart). In ten of the twelve cases albumin had been found in the urine
and was probably present in the other two, but the tests had been inadequate.32 He
added that generally the urine was dilute and low in urea content; these findings in-
dicated that urea was accumulating in the blood. It had often been detected by oth-
ers in such cases, and Snow suggested that a rise in circulating urea might be the
cause of some of the problems, including disease of the heart itself. In terms of treat-
ment he recommended, in view of the congestion, that blood-letting at the com-
mencement of the disorder should be beneficial, together with free purgation.
Snow was immediately challenged by William Addison.33 Dr. Addison was un-
convinced by Bright’s researches that the kidney was the source of the problem in
dropsy. Instead he attributed all the symptoms described by Snow, including the dis-
ease of the kidney, to a peculiar state of the system that might be induced by in-
temperance and a variety of other causes. He thought it more likely that the entire
human “economy” had been disrupted, and the cause could not properly be local-
ized to a single organ. He was ready to dismiss a laboratory discovery—albumin in
the urine—as a mere epiphenomenon providing no basic insight into the disease
process.
However, Dr. Golding Bird, recently appointed an assistant physician at Guy’s Hos-
pital, took up the torch for the new generation while still disagreeing with Snow’s
interpretation. He doubted whether increased urea in the blood contributed to the
symptoms. He noted that François Magendie (1783–1855) had injected urea into the
blood, and no bad effects had resulted. Bird’s citation of data from the laboratory of
Magendie, a skilled neurophysiologist and experimental pharmacologist, positioned
him with Snow as an advocate of a new approach to clinical medicine in which the-
ory and laboratory research structured one’s interpretation of diseases.34
This relatively early case report and discussion provides a glimpse of the young
Snow’s progress. He enjoyed an advanced grasp of basic concepts of pathophysiol-
ogy, especially when understanding a disease process required seeing the relation-
ships among various organ systems and tracing fluids from one body compartment
to another. He also demonstrated facility in performing postmortem examinations,
but his suggestion that blood-letting and purgatives could be the treatment of choice
shows that current options in therapeutics differed little from Watson’s and his
drawer of used blisters.35
Snow’s Early Publications

The free debate tradition in the Westminster shaped Snow’s earliest attempts at sci-
entific publication. From the outset he structured his written arguments as if he were
presenting a lecture: identifying a clinical or public health problem, surveying the
most recent medical literature on the topic, and dealing in advance with anticipated
objections—in short, using the medical journal as a forum to deliver the same mes-
sages he articulated in person at society meetings. He also floated trial balloons be-
fore his colleagues. Reading a paper allowed him to weigh criticism from his peers
and to decide whether the material was worth sending to a journal, having it pub-
lished as a pamphlet at his own expense (or both), or leaving it as a presentation.
The latter approach had some payoff, too, because reporters for the Lancet and LMG
generated detailed summations of papers. Because the reports of what transpired at
the medical societies usually included the reactions of each commentator, Snow could
also make his mark by responding to papers presented by his colleagues and the oc-
casional guest lecturer. Snow was no exception to the generalization that, for Lon-
don medical men in the nineteenth century, participation in medical society affairs
brought professional recognition, and regular publication was a critical aspect of ca-
reer advancement.36
His first four publications were letters to the editor written in response to articles
published in the Lancet and LMG. These letters were not, however, purely ad hoc re-
joinders. His reply to a Professor Goodeve on the use of arsenic to preserve cadav-
ers included a description and analysis of the experimental inquiry he had under-
taken during his student days. Thomas Wakley, editor of the Lancet, added a sentence
to the effect that Goodeve had reported no ill effects from his arsenic-treated ca-
davers. Wakley’s comment was as revealing as it was gratuitous. He was an old-school
surgeon who considered medicine solely an inductive science and appeals to exper-
imental medicine either faddish or harmful,37 but Snow was undeterred. In January
1839 he sent another letter to the Lancet because a recent article by John Goodman
on the “Physiology of the mechanical action of the heart” was “open to some ob-
jections.”38 Mr. Goodman had proposed that the auricles (atria) of the heart, being
less muscular than the ventricles, had no need for muscle fibers in their walls. He
argued that when the ventricles contracted, the diminution in their volume produced
a vacuum in the pericardium; atmospheric pressure acting on this vacuum squeezed
the auricles, emptying them into the ventricles without the need for them to con-
tract. He reasoned that the rib cage and the diaphragm were of such construction
as to be able to withstand “the pressure of the atmosphere, generally understood to
be 15lbs. on every square inch of surface. . . . The bony arch, by its unyielding
structure, presents itself to the oppressing forces with the firmness of the oak, in an
arched and resisting form, while the more yielding diaphragm, like the willow be-
fore the wind, bending beneath the atmospheric pressure, presents a concave, but
still resisting and equally protecting surface.”39
Snow began his rejoinder with the above quote, minus the sylvan flourish. He
agreed with Goodman that “the most delicate structures on the earth bear the pres-
sure of the atmosphere without detriment, so long as it is equal in all directions; a
distended bladder, and bubbles blown in soap and water, bear it because it is equal
inside and out; but this is not what Mr. G. means. . . .”40 The anatomy and physi-
ology of the thorax, according to Snow, did not support Goodman’s conclusions: “A
thorax 10 inches deep and 30 inches in circumference (not a very large one), has 300
square inches of surface, and would, in this case, have to resist a force of 4500 pounds,
or more than two tons; and, in addition, the diaphragm and the parts closing the
top of the thorax, would have to resist half as much; this would require thick walls
of cast iron, instead of mere flesh and bone. The truth is, that with very slight vari-
ations the pressure on every part of the thoracic viscera is exactly the same as on the
exterior of the chest.”41 The walls of the thorax are movable and elastic, and atmo-
spheric pressure on them and inside the lungs keeps the surfaces of the lungs in close
contact with the inside walls of the chest. The only variations in pressure between
inside and outside occur during inspiration and expiration. These are slight, Snow
explained, having quantified them by measuring his own intranasal pressure while
breathing with both a mercury and a water manometer.
The rest of the letter proceeded in like manner, with quotes from Goodman fol-
lowed by correctives drawn from current medical authorities and his own clinical
experience. He cited a recent paper by Magendie on blood pressure in dogs and sug-
gested that Goodman’s confusion stemmed from a misreading of Johannes Müller’s
Physiology, a textbook that served as the most advanced European treatise on the
subject during the 1830s and 1840s (Snow quoted from the English translation).42
Müller (1801–1858) belonged to a generation of natural historians who believed sci-
entific truth lay somewhere between the warring perspectives of their elders. For
Müller, Enlightenment physiology was too mechanistic and reductionist to account
for life forces, whereas the archetypal forms and Platonic ideas in Romantic Natur-
philosophie struck him as “fables.” His alternative, a “rational creative force,” was akin
to vitalism and served as the organizing principle in his discussion of embryology,43
but Snow used Müller’s principles of physiology to expose fallacies in Goodman’s
reasoning. As such, Snow was not out to score debating points at an opponent’s ex-
pense.44 His agenda was to advance the cause of a new scientific generation. Although
he lacked the resources to travel to France or Germany to study under such teach-
ers, he could read their works and position himself within the larger movement of
experimental physiology and chemistry that was transforming laboratory medicine.
Goodman could have done likewise and would not have gone astray had he fully un-
derstood the contributions of Müller and Magendie.45
A few months later another opportunity arose for Snow to enter the lists as an ad-
vocate of the new medical science. Someone who identified himself as “M.H.” sub-
mitted a brief note to the Lancet on “Respiration and asphyxia.” After commenting
on the various nerves responsible for stimulating respiration, “M.H.” argued that
what incites the first breath in the newborn cannot be the same mechanism that in-
cites breathing in the mature animal, because the latter depends on “evolved car-
bonic acid” produced by the animal after it has begun to breathe oxygen.46 The au-
thor went on to claim that asphyxia was closely allied to epilepsy because of the
convulsive nature of the attempts of the asphyxiated animal to breathe. Snow, in re-
ply, would very likely have alluded to the fact that the fetus in utero produces car-
bon dioxide that is chemically indistinguishable from that produced by the organ-
ism after birth. As he would write later, there was no reason in his mind to argue
that whatever causes the newborn to take its first breath is different from what causes
it to take its second or third breath.47 We will never know what Snow’s letter to the
editor contained because Wakley chose not to print it. Instead, the 25 May 1839 is-
sue of the Lancet included the following notice: “The remarks of Mr. John Snow on
a recent communication from M.H., on the physiology of respiration, have been re-
ceived. We cannot help thinking that Mr. Snow might better employ himself in pro-
ducing something, than to criticising the productions of others.”48 Wakley’s state-
ment can be read as a snub: Snow was an upstart trying to make a name for himself
by finding fault with his elders. It can also be read as the reaction of a prickly edi-
tor who thought Snow was criticizing him for including flawed articles in his jour-
nal, and it can be read as a gentle, if ham-fisted, warning by a senior colleague that
Snow should temper himself at so early a stage of his career. Whatever Wakley’s in-
tent, his comment was patently unfair to Snow. His first letter to the editor had de-
tailed arsenic experiments, and the Lancet had reported on Westminster Society meet-
ings at which Snow had read several papers on his research activities. He appears to
have taken offense, for he found a friendlier reception in LMG.49
Setting His Own Agenda, 1839–1843

Snow took Wakley’s comment to heart in that he refrained from sending further let-
ters to editors for the next few years and used this period to stake his own claim to
experimental territory and to establish areas of special interest. The territory he laid
claim to included the physiology of respiration and the chemistry and physics of in-
haled gases, with special attention to their implications for midwifery. Although at
first glance Snow’s early research and scholarship might seem eclectic in subject mat-
ter, his persistent interest was the physiology and pathology of respiration. He in-
vestigated the mechanics of breathing and ways to restore vitality when respiration
was interrupted. He studied the properties of inhaled toxins and gas exchange at the
tissue level. His understanding of factors that stimulated or depressed respiration,
or that supported or interfered with gas exchange, would prove enormously useful
when his major professional challenge became finding the middle ground between
preventing pain and suppressing breathing when administering anesthetic gases. In
addition, his deep understanding of the inhalational route of toxins led in a direct
path to his skepticism of the miasmatic origin of cholera. One should not read Snow’s
articles and presentations during the next half-dozen years as anticipations of
William T. G. Morton’s discovery of ether or of the return of cholera to England,
but it is highly unlikely that without the insights Snow derived from these forays into
medical science, he could have so successfully addressed the twin problems of anes-
thesia and cholera.
Snow’s emerging focus was in evidence at the Westminster Medical Society in March
1839, when Dr. Golding Bird read a paper on how carbonic acid gas produced death
in animals. Snow thought the paper so interesting that he requested a continuation
of the discussion. At the next meeting he began by noting that Bird’s paper had “in-
duced him to modify his opinion as to the modus operandi of charcoal fumes. He
had formerly entertained the idea that carbonic acid [carbon dioxide], like hydrogen
and nitrogen, produced death simply by the exclusion of oxygen; but the experiments
of Dr. Bird and Collard de Martine had convinced him of the contrary . . .”—that
carbon dioxide was deleterious, although he was not ready to accept Bird’s view that
it was an active poison.50 During the week after this presentation Snow had under-
taken several experiments on small birds and white mice using various mixtures of
atmospheric air, carbon dioxide, and oxygen. He described his results in detail and
concluded that oxygen could act, to some degree, as an antidote to carbon dioxide,
and that while the physiological action of carbon dioxide was unclear, its destruc-
tive powers might arise from constant stimulation of “the mucous membrane of the
air-cells.”51
This extended comment indicates Snow’s facility in planning and conducting a set
of experiments designed to answer a specific question. The chemical procedures he
described required a considerable amount of apparatus and of skill, and his com-
ments reveal an understanding of the physical and physiological principles involved.
He was particularly interested in the public health implications of these investiga-
tions. He cited a recent study that “death might be produced in an atmosphere which
supported the flame of a candle.” Because such a flame went out in an experimen-
tal atmosphere containing four percent carbon dioxide, “a fortiori, such an atmo-
sphere could not support life.”52 This conclusion was at odds with the reassurances
of chemists that charcoal-burning stoves lacking a chimney were safe for domestic use.
When Snow published his next paper in 1841, he provided further evidence that
he was carefully focusing his investigations (Table 4.1).53 From a general interest in
the chemistry and physics of inhaled gases, he began to turn his attention increas-
ingly to aspects of asphyxia, notably the increased resistance to blood flow through
the lungs and the site of the metabolic processes.54 He also showed a predilection
for inquiring into instances and mechanisms of poisoning, particularly if the poi-
sonous substance were inhaled. He demonstrated both an interest and a facility in
the invention and design of apparatus.
Snow resumed his publications with an article on deformities of the chest and
spine in children.55 While he focused on how abdominal enlargement might prove
to be the basic cause of chest deformities in the growing child, he was especially con-
cerned about the impact the deformities had on respiratory function and lung de-
velopment. About six months later Snow published a paper initially read at the West-
minster Medical Society on 16 October 1841.56 His explanation of the resuscitation
Table 4.1. Snow’s published research, 1836–1846

Experiment Apparatus Involved Involved Collateral sciences
Topic Datea conducted constructed respiration, gases poisons used
Arsenic as preservative of 1836–1837 X X X Chemistry
dead bodiesb
Action of recti musclesb 1838 Anatomy, physiology, physics
Mechanism of respirationb 1839 X Physiology, Physics
Action of recti musclesb 1839 Anatomy, Physiology
Distortions of chest in 1841 X Anatomy, pathology,
children with abdominal physiology, clinical case
enlargement report
Resuscitation of stillborn infants 1841 X X X Physiology, physics
Paracentesis of thorax 1841 X X Physiology, physics
Uterine hemorrhage with 1842 Physiology, clinical case
retention of placenta report
Circulation in capillaries 1843 X X Physiology, physics,
microscopy
New kind of pessary 1843 X Clinical case report
Lead carbonate poisoning 1844 X Pathology, chemistry,
clinical case report
Hemorrhagic smallpox 1844 Pathology, clinical case
report
Pericarditis after scarlet 1845c Pathology, clinical case
feverb report
(continued)
Table 4.1. Snow’s published research, 1836–1846 (Continued)

Experiment Apparatus Involved Involved Collateral sciences
Topic Datea conducted constructed respiration, gases poisons used
Atmospheres with 1846d X X X Chemistry, physics,

reduced oxygen and physiology
normal carbon dioxide
Strangulation of ileum in 1846 Pathology, clinical case
mesentery report
Alkaline urine 1846e X Chemistry, physiology,
clinical case report
aDate given is that of publication unless the article states specifically that the observation or experiment was carried out at an earlier time.
bReply to previous publication by another author.
cReports case that occurred in 1844.
dRefers to research conducted in 1839.
eReports case that occurred in 1842.
of the stillborn infant draws on several of his research interests, including respira-
tion and asphyxia, as well as a practical interest in designing apparatus. In a more
general way, it illustrates important features of Snow’s thought and writing and the
extent to which he had achieved a level of scientific competence at this relatively
early stage of his career. The paper is dense in ideas and material, while the style is
clear and brisk.
Snow began this paper by reviewing a number of physiological and philosophical
questions relating to asphyxia and marshaled experimental evidence to show that
animals tolerate lack of oxygen much better at low temperatures than at high tem-
peratures. He cited many physiological experiments performed by authorities he cited
by name, the best known being Lorenzo Spallanzani (1729–1799) and Marie François
Xavier Bichat (1771–1802). After explaining why many commonly used resuscita-
tion methods were unsatisfactory because they were at odds with this large body of
experimental data, Snow turned to the new device produced after his own plans by
Mr. John Read of Regent Circus and described its use and advantages.57 The appa-
ratus consisted of two syringes placed side by side, one to withdraw air from the
lungs via the mouth and the other to push fresh air into the lungs via the nostrils.
Atmospheric air, provided by an efficient device such as Read’s, ought to be suf-
ficient by itself to restore respiration if the asphyxia were reversible at all. Snow added
that should the physician desire to add oxygen, “oxygen gas can be generated in great
purity, in a few minutes, from chlorate of potash, by means of a spirit-lamp and a
small retort.”58 After a few comments on possible uses of mild electric shocks in stim-
ulating respiration, Snow mentioned the experiment he had performed on a guinea
pig to show that he could restore some heart action an hour after death by artificial
respiration. He concluded his paper with some observations on the mechanism that
causes the newborn to take its first breath—perhaps held in reserve from his never-
published reply to M.H. in the Lancet—and how long after cessation of placental
circulation fetuses of various ages would survive.
This paper seemed to stimulate the Westminster Medical Society almost as much
as Read’s apparatus was said to stimulate newborn respiration. The society took the
unusual step of extending discussion of the paper into the next two meeting ses-
sions, 23 and 30 October. For the most part, the many comments and criticisms from
the other members reflected the tradition of bedside medicine, although Mr. William
D. Chowne added a statistical dimension: He reviewed his records and found only
sixteen stillborns among his last 500 obstetrical cases, leading him to dispute Snow’s
one-in-twenty figure as grossly inflated. Mr. Forbes Winslow attacked Snow for not
distinguishing between two causes of asphyxia, plethora and collapse, and argued
that only blood-letting would help in cases of plethora. Many shifted the course of
discussion to the question of resuscitating nearly drowned adults and debated how
many minutes without breathing might pass before it became impossible to restore
respiration. Each speaker had a case report to prove the point he was making, often
flatly contradicting the lesson of someone else’s case report. Only Sir Benjamin Brodie
offered a comment that seemed on the same plane as Snow’s discussion of experi-
mental physiology, claiming that artificial respiration could not be effective if the
heart had stopped.59
When Snow was granted time to reply to these objections on 30 October, he had
obviously used the intervening period to prepare his remarks carefully. He turned
aside the plethora/collapse distinction by carefully defining his terms, arguing that
the correct current usage restricted the term asphyxia to “the pathological state oc-
casioned by the stoppage of the respiration.”60 He considered asphyxia a unitary phe-
nomenon, physiologically, and therefore the experimental data he had originally cited
were applicable. He also took up the question of the resuscitation of nearly drowned
adults. Many of the cases cited by the members at the previous meeting had occurred
in the Serpentine pond at Hyde Park, and the Royal Humane Society had erected a
receiving-house specifically for the purposes of treating such victims. Snow expressed
dismay that the society recommended immersion in a warm bath (always at the
ready) before attempting to restore respiration. Instead, the authorities should have
an apparatus like Read’s (adult-sized) in the boat that was sent out to pull the vic-
tim from the water and work to restore respiration before reaching the receiving-
house.
These remarks of Snow’s were only the lead-up to what he considered his con-
clusive rejoinder. Since delivering his own paper, he had located one in the Philo-
sophical Transactions of the Royal Society written by John Hunter, the eighteenth-
century surgeon and founder of the school of anatomy in Windmill Street. Hunter
had recommended a bellows for artificial respiration, designed on a principle almost
identical to Read’s two-syringe device. He had performed some experiments with his
bellows on a dog whose heart had been exposed and showed that the heart action
would flag soon after artificial respiration ceased and pick up again after artificial
respiration was resumed. He was able to restart the dog’s heart ten times using his
bellows, even after the heart had ceased to beat for as long as ten minutes. If Sir Ben-
jamin Brodie doubted the evidence of Snow’s own guinea pig experiment, he could
hardly maintain his objection in the face of this experiment by Hunter, whom Snow
considered “one of the greatest physiologists that ever lived.”61
Snow’s Evolving Scientific Thought

The paper on newborn resuscitation illustrates a complex method of attacking a
problem in medical science. Snow had found a comfortable balance among newer
perspectives in hospital and laboratory medicine and an updated version of bedside
medicine. For him the ideal form of clinical observation, whether conducted per-
sonally at the bedside or in hospital wards and supplemented by reports from med-
ical journals, consisted of a long series of cases that had been carefully recorded and
could be statistically analyzed, but conclusions were tentative unless confirmed by
laboratory findings. In this instance he had to resolve an apparent dichotomy be-
tween laboratory experiments showing that cold was desirable and accumulated bed-
side experience suggesting that heat was desirable. He rejected neither out of hand,
however. Instead, he offered a distinction to try to reconcile the laboratory and the
bedside findings—warmth might be preferable if the infant were to begin sponta-
neous breathing soon; cold might be preferable if attempts at resuscitation were go-
ing to last indefinitely.
Snow also demonstrated ease in moving among different scientific disciplines. His
resuscitation paper was based largely on applied physiology, but he also made de-
tours into chemistry, anatomy, and physics just as readily as he moved between lab-
oratory and bedside. It was a pattern he followed his entire career, specifying the pre-
cise relationship between medicine and its collateral sciences.62 Snow was a
systems–network type of reasoner. He seldom dealt with linear chains of cause and
effect but rather with interacting networks of causes and effects. He viewed the hu-
man organism, and the world it inhabits, as a complex system of interacting vari-
ables, any one of which, isolated temporarily for careful study, might provide a use-
ful clue to the clinical–scientific problem—but only when seen in its proper context,
and only when the variable, having once been isolated for study, was then put back
into its place in the system and restudied in its natural environment. The heat–cold
discussion in the stillborn-resuscitation paper provides a limited example of this
mode of thought. At the chemical level, the temperature controls the rate at which
reactions occur. If a chemical reaction consumes oxygen, it will consume it faster if
the temperature is increased. At the physiological level, changes in temperature will
affect the animal’s nervous system and occasionally stimulate a nervous reaction, in-
cluding a reflex inspiratory effort. Snow was equally comfortable isolating these vari-
ables for study at one level of biological organization or seeing their interactions at
the multiple levels that make up the intact organism within its environment. In some
clinical circumstances the positive effects of heat in stimulating the nervous system
compensate for any negative effects heat might have in causing increased consump-
tion of the limited oxygen that is available. In other circumstances the opposite would
hold true.
Snow showed further evidence of his understanding of the physics and physiol-
ogy of respiration, as well as his ability to put that knowledge to clinical use, when
he discussed a new apparatus for paracentesis of the thorax at the Westminster two
months after delivering the paper on stillborn resuscitation.63 Paracentesis is the
withdrawal of fluid from the pleural space (the space surrounding the lungs) to al-
low the lungs to expand fully and relieve labored respiration. Conventional meth-
ods of draining fluid from the pleural cavity allowed air to flow in as the fluid was
withdrawn. Snow’s explanation of why this was undesirable began with a brief re-
view of the mechanics of respiration. “In the normal condition there is no vacant
space within the thorax. The pleura on each side of the chest is a vacant bag, merely
lubricated on the inner surface with serum; and the pulmonary and costal portions
glide gently over each other during respiration. Whenever any fluid, whether a
liquid or a gas, accumulates within the pleura, it is desirable that we should get
rid of it.” When the diaphragm is depressed during normal inspiration, the pres-
sure in the lungs becomes slightly less than the pressure of the atmosphere, and
air comes in through the trachea, expanding the lungs to fill the space made avail-
able. “But so soon as an artificial opening is made into the pleura, the atmospheric
pressure is at once equal on the inner and outer surfaces of the lung on that side;
it collapses in accordance with its own elasticity, and remains unaffected by the
motions of the ribs and diaphragm.” When the diaphragm is depressed under
these circumstances, it sucks in air through the opening in the pleura, which com-
presses the lung and does not allow it to expand. “It follows from this that at the
completion of paracentesis, performed in the usual way, the lung must be col-
lapsed, and the space between it and the ribs occupied by air, provided all the liq-
uid has been removed. And, in fact, with the stethoscope applied to the chest dur-
ing the operation, the air can be heard passing in by bubbles as the liquid flows
out.” By replacing one fluid in the pleural space (pus or serum, depending on the
underlying disease process) with another fluid (air), one has done nothing to re-
lieve the basic problem.64
Snow then outlined an ingenious procedure that would work. He believed that,
“provided the serum can be removed without making a communication between
the external air and the pleura, I do not see why tapping may not be performed
on the thorax with . . . safety and success. . . .” A Glasgow physician, Dr. David-
son, had tried but failed to prevent the ingress of air by applying a cupping glass
over the canula. Snow showed his colleagues an instrument manufactured for him
with great accuracy, again by Mr. Read of Regent Circus. It consisted mainly of
an outer hollow tube (canula) and an inner solid tube (trocar). Both trocar and
canula had beveled ends so that when one was placed within the other, the entire
apparatus formed a thick, solid needle suitable for puncturing the pleural cavity.
The trocar could then be withdrawn, leaving the canula as a hollow tube con-
necting the pleural cavity with the outside, suitable for sucking out fluid. The
novel feature was a stopcock near the outer end of the canula. This had been ex-
tended so that the accurately machined trocar, which bore a mark, could be with-
drawn beyond the stopcock while maintaining an airtight fit. The stopcock would
then be closed, the trocar removed, and an elastic tube connected at one end to
a double-action valved syringe like a stomach pump. Fluid could thus be removed
without allowing air to enter, and “the integrity of the chest as a pneumatic ap-
paratus is not impaired during the operation.”65 With characteristic generosity,
driven by the belief that the practice of medicine should be a public service, he
laid before the society a drawing of the instrument that any member could have
devised by his own instrument maker. Snow had provided both a clear physio-
logic rationale and a practical way to bring that wisdom to the bedside for the re-
lief of the patient.66
Deeper Into Asphyxia

Snow’s interest in the mechanisms of asphyxia was again evident two years later
in a published paper on circulation in the capillary vessels.67 Again, he reasoned
back and forth between the realms of physiologic theory and practical therapeu-
tics. The medical question at issue was whether the pumping force generated by
the heart fully accounted for the circulation of blood in the capillaries. A number
of experimental findings suggested that it did not, and he reviewed the relevant
literature. He then proposed a unifying explanation: Capillary flow was assisted by
the “attractions and repulsions” caused by the “mutual changes which take place
at the capillaries, between and blood and the tissues.”68 As some substances move
out of the bloodstream to nourish the surrounding tissues, and as other substances
move into the bloodstream to be carried away from the tissues, all these processes
of exchange create and impart a motive force to the flow of blood in the capillar-
ies.69 One piece of evidence he offered in support of his hypothesis was the arrest
of the pulmonary circulation in a state of asphyxia. Once the exchange of gases
has ceased to occur within the pulmonary capillaries, the motive action of the heart
is insufficient to propel the blood through the pulmonary circulation. He argued
similarly that camphor and other volatile medicines were capable of assisting dif-
ficult and impeded respiration. By virtue of the fact that they were exhaled with
the breath in chemically unchanged form, these medications exerted an increased
attractive force upon the pulmonary circulation that could help to remedy the ef-
fects of certain lung diseases.
Snow suggested that this group of medicines might be called “diapnetics,” based
on their analogy of function with diuretics—the former enhanced excretion through

the lung, the latter through the kidney.70 His reason for claiming the privilege of
naming this group of medicines was a peculiar one. He did not claim to have dis-
covered any of the medications. He claimed, instead, to have discovered the fact that
their common medicinal and chemical properties allowed them to be classified as a
family of agents. The family resemblance lay both in the chemical fact that they un-
derwent no alteration in the body before they were exhaled and in the (purported)
therapeutic fact that they could assist impeded respiration. While the individual
drugs had been known previously, Snow now suggested that the profession had failed
to appreciate the family resemblance and its underlying chemical mechanism. He
was tentatively exploring the notion that a hypothesized family resemblance among
a class of drugs could henceforth guide his research into the properties and mecha-
nisms of these and related drugs, both in the laboratory and at the bedside, and his
attempts to better integrate laboratory findings with bedside observations. Chem-
istry was the laboratory science Snow was most likely to employ. If microscopic
examination was of value, however, he referred to what others described. He may
have considered this collateral science insufficiently developed to be helpful in many
instances.71
Although his research focus was on respiration, Snow remained engaged in the
full range of topics discussed at the Westminster Medical Society.72 When com-
menting he occasionally referred to experimental work of his own, such as the use
of dogs and cats as subjects, differences between ordinary respiration and cough,
chemical studies of the absorptive actions of the gut, experiments relating to dia-
betes, and the effects of woorara poison on guinea pigs.73 In February 1839 he com-
mented about malformations in birds and reptiles, and in April he discussed ap-
propriate treatment of mental diseases. Some years later he discussed mind–body
interdependence, the relationship between plague and outside temperature, and how
he had counted an adult lion’s heart rate at sixty by observing the pulsations of the
radial artery.74
Snow’s may have been a shy man who either kept to himself or kept his colleagues
at a polite social distance, but he did have some close friendships. One was surely
Peter Marshall, the surgeon in Greek Street who lived near him. In three publica-
tions, Snow referred to Marshall as “my friend.”75 Marshall was also Snow’s general
practitioner. In the summer of 1845, when he developed a protracted illness sug-
gesting a kidney disease, Marshall undertook his medical care, eventually consulting
Drs. Richard Bright and William Prout, both notable authorities on kidney disor-
ders.76 They persuaded him to take a vacation, an unusual practice for him. He vis-
ited his friend and one-time roommate, Joshua Parsons, in Somerset. Parsons was
surprised to find that Snow was now taking a little wine and eating some meat. The
physicians must have convinced him that teetotalism and a strict vegetarian regimen
were unsuited to his delicate state of health. He ended his summer vacation with a
short visit to the Isle of Wight and then returned to London and resumed his nor-
mal schedule.77
Seeking an Academic Position

The dual qualification MRCS and LSA that Snow obtained in 1838 was the basic le-
gal requirement for general practice, but Snow wanted more than what the life of a
typical GP had to offer. In addition to involvement in medical societies and experi-
mental research in his home laboratory, he wanted an academic post and certifica-
tion as a physician.
Two pathways to an academic post in medicine existed at the time. Each hospital
appointed two or three surgical and medical “visitors.” These were unsalaried posts,
but they brought their occupants many referrals and prestige. Well-heeled patients
expected their surgeon or physician to be experienced, and where better to gain it
than on the bodies of those who had no choice but to go to a hospital? In London
the most sought-after visitor posts were at the hospital-based medical schools, which
gave one an academic appointment and often first chance at the second pathway, a
lectureship in surgery, medicine, or obstetrics. There were, of course, other subjects
to teach and therefore other posts available. Qualification as a surgeon made “Mr.
Snow,” as he was referred to in the medical journals, eligible for an appointment as
surgical visitor, and Richardson states that he found a vacancy in the outpatient de-
partment at the Charing Cross Hospital. However, he is not listed as such on any
records housed in the hospital archives, so at best he had an informal arrangement
that never eventuated in a formal position.78
Only physicians were eligible to be medical visitors, and many medical school lec-
tureships also fell to doctors of medicine; whatever his ultimate goal, Snow decided he
wanted to attain the triple crown in his field. The bachelor of medicine (MB) was a
prerequisite, and only Oxford and Cambridge had offered these degrees in England for
several centuries, but since 1828 the University of London in Gower Street, within walk-
ing distance of Snow’s flat, had offered both degrees. Table 4.2 lists the requirements
for the MB, along with remarks on Snow’s ability to meet each of them. The Hunter-
ian School of Medicine was a “recognized” institution, which permitted Snow to by-
pass the required lecture courses and proceed directly to the examination when he felt
Table 4.2. Prerequisites for a bachelor of medicine (MB) degree

examination at the University of London in 1844
Prerequisites Snow’s Status
At least 19 years old Age 30 in 1843
Degree in arts from recognized university, No degree in arts; exempted from
or passed University of London matriculation examination after
matriculation examination translating a portion of Celsus’s
De Re Medica
At least 2 years’ attendance at recognized Completed full curriculum, Hunterian

medical school School of Medicine; one year of
courses in Newcastle
Attended course of lectures in four of the Attended ten of these courses, either
following subjects: descriptive and surgical at the Hunterian or in Newcastle
anatomy, general anatomy and physiology,
comparative anatomy, pathological
anatomy, chemistry, botany, materia
medica and pharmacy, general pathology,
general therapeutics, forensic medicine,
hygiene, midwifery, surgery, medicine
Nine months of dissection Completed at the Hunterian
Course in practical chemistry and ability Satisfied at the Hunterian; publications
to carry out common laboratory procedures demonstrated this facility as well
Practical knowledge of preparation of Qualified as LSA
medicines
Source: University of London Calendar, 1844, 44–45; Alun Ford to David Zuck, 27 February 2001; Julia
Walworth, University of London Library, to David Zuck, 4 August 1989.
he was prepared.79 He took the examinations given on 23 November 1843. To pass he

had to demonstrate both theoretical and practical knowledge, answering, among oth-
ers, questions on how to tell blood spots from rust spots, the poisonous dose of lau-
danum in an infant and the symptoms it would produce, the determination of preg-
nancy in a variety of cases, the anatomy of the portal system, the nature of ciliary motion,
and the auditory apparatus of the cuttlefish, a fish, and a reptile. He passed, placing in
the second division.80 Upon gaining this degree, custom permitted him to replace his
surgeon’s designation with the physician’s title, Dr. Snow, although it was increasingly
expected that “Dr.” should be reserved for recipients of the MD.81
A year later he was among the candidates at the University of London who hoped
to pass the arduous oral and written examinations for the MD degree. All had to
show proficiency in philosophy and logic in the form of written commentary on ex-
cerpts from Locke, Berkeley, and Leibnitz. All had to translate passages from French
and Latin. They had to discuss a case of rheumatism accompanied by chest pain and
a heart murmur, a surgical case involving management of bladder stones, and a mid-
wifery case with secondary arrest of labor followed by spontaneous delivery. Finally,
they were asked questions on displacement of the heart, scarlet fever, pneumonia,
pleurisy, diarrhea, and delirium tremens.82 This time Snow was placed in the first
division. Passing this academic milestone also provided a suitable occasion for hav-
ing his portrait painted for the first and only time (Fig. 4.1).83 Snow now possessed
the credentials required for a medical school post.
The medical schools of London were in considerable flux at this time; those of the
large teaching hospitals, with their attached clinical facilities, were growing in stature
and influence and displacing the private ones, a number of which, like the Hunterian,
had closed. In the eastern part of London, however, the private medical school in Alders-
gate Street had for some time provided stiff competition for the nearby St.
Bartholomew’s Hospital Medical School. For many years the Aldersgate school had
boasted a string of popular lecturers that the hospital school could not match and for
some time brought St. Bartholomew’s (“Bart’s”) to the brink of closure.84 Alfred Bar-
ing Garrod, a friend of Snow’s through the Westminster Medical Society, had joined
the Aldersgate Street School in 1844 as a lecturer in materia medica. Two years later
the lectureship in forensic medicine became vacant, and Snow was appointed. His work
on poisons and his knowledge of obstetrics would have been applicable to the sub-
ject.85 His first lectures on forensic medicine were duly advertised in the fall issue of
the Lancet: one course to be offered in the summer session of 1847. Enrollment re-
quired a ticket costing two pounds, two shillings.86 Snow thought highly enough of
his academic appointment to add his description as “lecturer in Forensic Medicine at
the Medical School, Aldersgate Street” to several papers published in 1846 and 1847.87
However, the school’s fortunes soon fell as its rivalry with Bart’s took a dramati-
cally different turn. Some five years earlier, Bart’s had scored a double victory over
its rival by attracting Mr. James Skey, a well-respected lecturer in anatomy, away from
the Aldersgate and by appointing the extremely popular James Paget as its new lec-
turer in physiology. As the years went by it became clear that the Aldersgate School
Figure 4.1. John Snow, age about 33 (portrait by Thomas Jones Barker, courtesy of Geoffrey
Snow; black-and-white reproduction supplied by David Zuck).
could not offer a staff of lecturers in the most basic subjects to rival the reputation
of the new Bart’s faculty.88 It was in disarray by the fall of 1848; it was late in pub-
lishing a prospectus for the coming session, and when it did the lecturer in forensic
medicine was not mentioned. In all likelihood, however, Snow offered the course.
The school closed completely at the end of the 1848–1849 session, and the final re-
ward from his short association with it was the privilege of helping pay off its debts.89
Alfred Baring Garrod transferred to University College Hospital, but Snow appar-
ently made no move to seek another academic post.
Snow in 1846: The Mind Prepared—For What?

In his first ten years out of medical school, Snow was able to make a living as an
urban general practitioner. He attained considerable scientific skill, some degree of
professional recognition, and a level of education and certification that took him
near the top of his profession. In some other ways he seemed hardly to have left the
rural north. He cared daily for the same class of working poor among whom he had
grown up in York, reinforcing his generally egalitarian outlook. His austere lifestyle
fit well with his habitual moral rectitude. He had personally investigated a wide range
of medical problems, many of them suggested by his experiences as a practitioner.
He had identified with and learned from a group of authorities who represented the
most advanced thinking in physiology and chemistry. He had developed rare skills
that allowed his mind to flow easily among the three realms of bedside, hospital, and
laboratory medicine. Given any medical issue, Snow could readily imagine what
would be seen when one examined a patient at the bedside, what sorts of statistical
regularities one might uncover by considering a series of cases, how one might elu-
cidate basic mechanisms through laboratory experiments—and, finally, how one
could take back to the bedside the fruits of one’s research to improve the care of the
patient and the general public health.
Snow’s research skills were widely applicable, but he tended to focus rather than
scatter his research efforts. From the beginning he had identified respiration and as-
phyxia as his special province. He devoted special attention to the effect of respira-
tion on the circulation and the chemistry and physics of inhaled gases. He was prov-
ing adept at designing apparatuses based on a clear understanding of underlying
scientific mechanisms and well adapted to practical needs. He had illustrated his
skills and interests in his entire series of scientific publications, perhaps none more
striking than the 1841 paper on the resuscitation of the stillborn infant. It was in-
formed by major philosophical questions: What exactly was the dividing line be-
tween life and death, living and nonliving? What was the basic difference between
an infant born apparently dead but destined to live, and one who would remain
dead? What made states of near-death reversible or irreversible? What was the rela-
tionship between the oxygenation of the organism and its state of sensibility or in-
sensibility to stimuli such as pain? How could asphyxia be distinguished from other
states that resembled it but that had fundamentally different properties? What role
did temperature play in all of these processes? All of these questions provided a
framework for the scientific investigation of related puzzles that might present them-
selves to Snow in the future. As 1847 approached Snow had much to be thankful for.
Nonetheless, he remained a relatively obscure general practitioner, little known
outside two London medical societies and a small private medical school whose best
years were behind it. He still had a flat in Frith Street, and he still worked long hours
serving working-class patients for the most part. The time and energy available for
medical research were limited. No change for the better was on his horizon. Then
came news about ether anesthesia.
Notes
1. Richardson, L, ix.
2. Mozart had lodged in Frith Street, Constable had lived there, and Hazlitt had died there.
Hare, Walks in London, 126–132; Weinreb and Hibbert, London Encyclopaedia, 295, 779; Cun-
ningham, Hand-Book of London, 193, 445–46.
3. Robson, Royal Court Guide, 29. We are grateful to Agnes H. Widder of the Michigan
State University Library for providing research assistance with the city directories and 1841
census reports.
4. UK Home Office, 1841 Census, H.O. 107/730/3, 10–32 (County of Middlesex, Liberty of
Westminster, parish of St. Anne-Soho; Registrars’ districts, Strand/St. Anne Westminster/3).
The population may be somewhat inflated because enumerators included overnight visitors.
5. Ibid., 15–16; Pigot and Co., Royal Street Directory of London for 1840, 122.
6. Pigot and Co., Royal Street Directory of London for 1840, 122; Robson, London Directory
for 1840, 132. The first city directory listing for Snow that we have found was in 1840. In 1841
the enumerator wrote Williams; UK Home Office, 1841 Census, H.O. 107/730/3, 27. Ten years
later, the spelling changed to Williamson, the same used by Richardson; 1851 Census, H.O.
107/1510/82; and Richardson, L, ix.
7. Robson, London Directory for 1838, 163; for 1839, 129; for 1840, 132; for 1841, 136–37;
for 1843, 121. “Physicians,” Pigot & Co., Directory of London, 1839, 180–81.
8. S. Snow, JS-EMP, 331–32. For a discussion of the travails of the fledgling Victorian physi-
cian trying to set up practice in a town where he has no social relations and connections, see
Peterson, Medical Profession, 90–135. Peterson relies heavily on the fictional Dr. Stark Munro,
a character created by Arthur Conan Doyle in his semiautobiographical novel The Stark Munro
Letters (1895). Peterson argues that the problems faced by Stark Munro were typical of the
entire Victorian period. Doyle provided a condensed portrayal of Dr. Stark Munro, with “more
in his brains than in his pocket,” in the better-known character of Dr. Percy Trevelyan in the
Sherlock Holmes story “The Resident Patient”; Doyle, Memoirs of Sherlock Holmes, 177–78.
We are grateful to Christopher Hamlin for pointing out that contemporary medical autobi-
ographies, such as that of Thomas Watson, confirm these points; private communication.
9. On Diamond see Gilman, The Face of Madness.
10. Robson, London Directory for 1841, 136–37; UK Home Office, 1841 Census, H.O.
107/730/3, 11.
11. Richardson, L, xii; Digby, British General Practice, 79.
12. In the 1830s some medical men were paid as little as 2 shillings per person per year;
Peterson, Medical Profession, 114–15.

13. John Simon, as head of the medical department of the Privy Council, created a Labo-
ratory Investigation Division in 1865 that employed several physicians on a part-time basis
and whose employees eventually became leading medical scientists; Lambert, Sir John Simon,
279–84. Full-time positions attached to medical schools employing physician–scientists re-
mained the vision of reformers rather than an accomplished reality; Worboys, Spreading
Germs, 27.
14. Richardson, L, ix–x, xl. He also stated that Snow in later life regretted not having mar-
ried and had children, noting vaguely, “the fates had been against him permanently on that
score”; Ibid., xxxviii.
15. Ibid., x, xxxiii. A reporter at a December 1838 meeting of the Westminster Medical So-
ciety noted that “Mr. Snow now made some observations in a very low tone, and consequently
his meaning could not be very well caught”; LMG 23 (1838–39): 426. The reporter for the
Lancet at the same meeting apparently was sitting closer to Snow and was able to report his
statement, which had to do with chemical affinity between gases and the role that played in
the amount of oxygen the lungs could extract from the air; “Westminster Medical Society,”
Lancet 1 (1838–39): 419. Similar remarks about Snow’s lowness of voice may be found in
“Westminster Medical Society,” LMG 23 (1838–39): 954.
16. Richardson, L, xxxix.
17. Ibid., xii.
18. Ellis, CB, 121.
19. Snow listed himself as a general practitioner in the 1845 London Medical Directory but
by 1847 had changed his designation to “physician and accoucheur,” indicating the signifi-
cance he attached to obstetric work in his evolving career; S. Snow, JS-EMP, 209. Between Oc-
tober 1849 and September 1850, fully half the new patients Snow added to his practice were
obstetrical cases; Ibid., 286. By then he was also increasingly restricting himself to adminis-
tering anesthesia.
20. Peterson, Medical Profession, 99–100.
21. We might wonder how Snow was regarded as a practitioner by his peers. At least some
colleagues viewed Snow as a shrewd clinician who could be a valuable ally when faced with a
puzzling case. Richardson described Snow’s talents: “He had great tact in diagnosis; an ob-
servant eye, a ready ear, a sound judgment; a memory admirably stored with the recollection
of cases bearing on the one in point, and a faculty of grouping together symptoms and fore-
shadowing results, which very few men possess.” Richardson, L, xxxix. Richardson stated that
another close associate of Snow’s who had in fact consulted with him on a number of diffi-
cult cases, Mr. Peter Marshall, would concur item by item with this description. Richardson’s
praise was part of a eulogistic memoriam, and Richardson did not meet Snow until fifteen
years after these events. Nevertheless, Snow’s published case reports and commentaries seem
to lend some support to Richardson’s opinion.
22. Richardson, L, viii–ix. The importance of medical societies for the development of
nineteenth-century medicine, of which Snow’s experience might be seen as a microcosm, is
stressed by S. Snow; JS-EMP, 173.
23. S. Snow, JS-EMP, 172. The annual sessions of the medical societies generally ran from
early October to early May.
24. Lancet 1 (1842–43): 327; Lancet 1 (1843–44): 163. Snow’s election as vice-president was
noticed in AMJ 1 (1853): 218; he added “Vice-President of the Westminster Medical Society”
to his by-line in the fourth paper of an eight-part series, “On narcotism by the inhalation of
vapours,” LMG 41 (1848): 330–35.
25. “The Westminster Medical Society,” BMJ 2 (1896): 26; Hunt, Medical Society of Lon-
don, 3–5, 15–18, 73–74. We are grateful to Roy Porter and Caroline Overy for aiding us in
identifying these sources. Richardson apparently was still grieving the old Westminster name
when he reported in 1858 that the venerable organization had “sunken into” the Medical So-
ciety of London; L, viii. However, it was very important that the Medical Society of London’s
title to its property not be jeopardized, because it was precisely as a result of owning its own
meeting house that the new amalgamated society could be financially secure.
26. Snow’s election as fellow of the Royal Medical and Chirurgical Society was announced
in M-CT 26 (1843): xxii.
27. On the social and political orientations of the society, see Desmond, Politics of Evolu-
tion, 223–25.
28. See Hardcastle’s requirements for certification as an apothecary; Society of Apothe-
caries, “Court of Examiners entrance books,” MS 8241/1, 213.
29. A reflection of the new interest in medical affairs outside Britain was the inauguration
of the British and Foreign Medical Review in 1836.
30. “Westminster Medical Society,” Lancet 1 (1839–40): 441–44. Snow’s paper was “The
anasarca which follows scarlatina”; only the reporter’s summation exists. Scarlet fever was a
dreaded disease right up to the introduction of sulphonamide drugs in the mid-1930s; valvu-
lar disease of the heart resulted from the associated rheumatic fever. Bright himself was aware
of the causative association between kidney disease and an earlier attack of scarlet fever; Peitz-
man, “From Bright’s disease to end-stage renal disease.” We are grateful to Dr. Peitzman for
the further information that William Charles Wells and John Blackall, between 1810 and 1820,
had described the relationship between scarlet fever and dropsy, although they did not view
the dropsy as representing renal disease. While Snow’s observations were thus not original,
the recognition of the relationship between scarlet fever, dropsy or anasarca, kidney disease,
and albumin in the urine was still fresh in 1839, thereby justifying the reporting of a series of
cases; e-mail message; Peitzman to Brody, 27 February 2002. See also Maher, “Origins of Amer-
ican nephrology.”
31. R. Bright, Reports of Medical Cases and “Cases and observations.” See also P. Bright, Dr.
Richard Bright, 131–42.
32. The test most commonly used for albumin in the urine at that date was gross and
qualitative—heating a teaspoon of urine over a candle flame to see whether coagulation
occurred; Peitzman, “Bright’s disease.”
33. No first name is given, but the content of the remarks make it unlikely to have been
Thomas Addison of Guy’s Hospital.
34. Golding Bird, it appears, by this time accepted the basic fact that urea accumulated in
the blood in Bright’s disease of the kidney. In 1833, as a young student at Guy’s, he had made
himself somewhat notorious by engaging in a running debate (in the pages of the LMG) with
another student of Bright’s, George Owen Rees, in which Bird had taken the losing side on
the question of whether urea was increased in the blood; Peitzman, “Bright’s disease,” 316. See
also Coley, “The collateral sciences in the work of Golding Bird.”
35. Snow’s prescribing habits and general mode of practice were not noticeably different
than those of the usual general practitioner of his time; see Earles, “Prescription records,” CB,
xliv–l. The new discoveries resulting from hospital and laboratory medicine were only slowly
applied to therapeutics and did not affect daily practice until very late in the nineteenth cen-
tury; see Warner, The Therapeutic Perspective, and Durey, The Return of the Plague, 133.
36. S. Snow notes the importance of journal publication in advancing the careers of physi-
cians; JS-EMP, 184. She also notes that when Snow listed his name in the 1845 London Med-
ical Directory, he mentioned five papers he had published and also noted that he was inven-
tor of a new instrument for paracentesis of the thorax and of a sponge pessary; Ibid., 209.
37. Snow, “Arsenic as a preservative” (1838). Wakley’s comment seems gratuitous because
Snow had himself admitted that not all dissectors fell ill and that illness might depend on
variables such as room temperature. Wakley was an advocate of the clinical–pathological

method introduced to London medical schools by Scottish trained surgeons; see editorials
about the need for ready access to autopsies and complete case notes for students walking the
wards in Lancet 1 (1836–37): 16–17. For his view of scientific medicine, see the book review
that “wisely advises” that “the progress of medicine, as an inductive science, is retarded by the
construction of hypothetical theories . . . and by the deduction of general principles or con-
clusions, from a limited number of facts”; Lancet 2 (1831–32): 153.
38. Snow, “Mechanism of respiration,” (1839). Goodman’s paper, read to the Manchester
Medical Society, had appeared in Lancet 1 (1838–39): 515–19.
39. Goodman, Lancet 1 (1838–39): 515.
40. Snow, “Mechanism of respiration,” 653.
41. Ibid.
42. In Goodman’s defense, Magendie and investigators following the line of Lavoisier’s in-
vestigations of the chemistry of respiration were proposing new concepts in physiology so
rapidly that one medical man complained, “How often does it fall to the lot of the student of
physiology to unlearn what he has been at pains to acquire!” See Williams, Observations, 7.
43. Desmond, Politics of Evolution, 342, 346–47.
44. For a contrary interpretation, see P. E. Brown, “Autumn loiterer” and “Another look.”
Snow’s harshest critic, Brown considered him an upstart who sought instant visibility by at-
tacking an older, established medical man.
45. For brief synopses of the work and influence of these two figures in nineteenth-
century medical science, see Porter, Greatest Benefit, 327–29, 333–34, 337–38. Müller and Ma-
gendie were perhaps less influential than the students they trained—Hermann von Helmholz
(1821–1894) and Karl Ludwig (1816–1895) in Müller’s case, Claude Bernard (1813–1878) in
Magendie’s. Snow lacked the expanded laboratory facilities those investigators enjoyed some
years later on the Continent. Snow remained in the generation of experimental physiologists
who mostly studied intact animals and who had limited abilities to derive quantitative data.
The capability of isolating specific organs and tissues for physiological experiments and de-
riving precise measurements of their functions was beyond Snow’s facility at that time.
46. “M.H.,” “Note on respiration and asphyxia,” Lancet 2 (1838–39): 240.
47. Snow, “On asphyxia, and the resuscitation of still-born children” (1841–42), 227.
48. Lancet 2 (1838–39): 352.
49. Snow did not publish in the Lancet again until 1846, when he sent a brief epistle at-
tacking homeopathy, with which he believed Wakley would sympathize; Lancet 1 (1846): 229.
Indeed, Wakley appended a favorable comment.
50. “Westminster Medical Society,” LMG 24 (1838–39): 60, 62.
51. Ibid., 61. Snow published these results several years later; see “On the pathological ef-
fects of atmospheres vitiated by carbonic acid gas, and by a diminution of the due propor-
tion of oxygen” (1846). Because it is difficult in this article to separate the experiments he un-
dertook in 1838 from those that came later, we have relied on the synopses reported in the
medical journals.
52. Ibid.
53. We have omitted from Table 4.1 Snow’s letter “On the use of the term ‘allopathy’“(1846),
in which he dismissed homeopathy as an unscientific fad. The letter is not properly a scien-
tific report but rather an expression of political opinion.
54. S. Snow agrees that the contents of these early papers show Snow concentrating on res-
piration, but she also claims that he indicated an equal interest in “epidemic disease”; JS-EMP,
203. We have found no evidence of the latter.
55. “On distortions of the chest and spine in children” (1841).
56. Snow, “On asphyxia, and on the resuscitation of still-born children” (1842); “West-
minster Medical Society,” Lancet 1 (1841–42): 132–34. Shephard considers this paper partic-
ularly significant for Snow’s later anesthesia research; JS, 45.
57. Owen, “A man called Read.” Read (1760–1847) was born in Sussex and trained as a hor-
ticulturalist. He invented a brass syringe for spraying plants and, having read reports of deaths
from poisoning, modified it for use as a stomach pump. He was taken up by Sir Astley Cooper
and opened a workshop in Southwark, near Guy’s Hospital, moving later to Oxford Circus.
Versions of his pump, which was used also as an enema syringe, are illustrated in Brockbank,
Ancient Therapeutic Arts, 53–56.
58. Snow, “On asphyxia,” 226.
59. “Westminster Medical Society,” Lancet 1 (1841–42): 149–51.
60. “Westminster Medical Society,” Lancet 1 (1841–42): 212.
61. Ibid., 213; Hunter, “Proposals for the recovery of persons apparently drowned,” dis-
cussed by Zuck, “Diagnosis of death.”
62. The remarks in which Snow most fully developed his vision of medicine and the col-
lateral sciences came later, when he assumed the presidency of the Medical Society of Lon-
don; “Medical Society of London,” Lancet 1 (1855): 292.
63. Snow, “On the paracentesis of the thorax” (1841).
64. Ibid., 705–06.
65. Ibid., 707. In a footnote the editor of LMG added that although Snow had provided a draw-
ing of the instrument, the description in his text was so clear that it was not thought necessary
to have an engraving made. According to Zuck the innovative nature of Snow’s apparatus had
not been fully appreciated; “John Snow on paracentesis of the thorax.” His invention was the pre-
cursor of all trocars and canulas and all exploring and spinal needles fitted with a stopcock, of
which there are many to be found in instrument catalogues. Until 1920 the routine treatment for
empyema was still rib resection and open drainage, and many died as a result. Matters came to
a head during the 1918–1919 influenza epidemic, when a large number of victims suffered from
the complication of streptococcal empyema. The death rate among American servicemen as a re-
sult of open drainage was so appalling, seventy percent in some centers, that an Empyema Com-
mission was set up to find the cause. Its report pointed out the fatal error of the neglect of the
physiology of the open chest wound; Coope, Diseases of the Chest, 376–77.
66. After Snow presented his new instrument for paracentesis, he had to defend the propo-
sition that it was bad for air to be admitted into the pleural space as the pathologic fluid was
withdrawn. Dr. William Addison, Dr. Frederick Bird, and Dr. Golding Bird all defended the
view that air in the pleural space was harmless—or at any rate, that as air was much more
easily compressible than a liquid, replacing the pathologic fluid with air would be a thera-
peutic advantage. Snow had to go back and restate the basics of the physics and physiology
of respiration, adding that while air was an elastic and compressible fluid, in the pleural cav-
ity it would expand during inspiration and be compressed during expiration, thereby im-
peding lung movement. In this instance, at least, resistance to Snow’s ideas crossed the “gen-
eration gap” within the society; “Westminster Medical Society,” Lancet 1 (1841–42): 484–86.
67. Snow, “Circulation in the capillary blood-vessels” (1843). Snow had mentioned his pre-
ferred theory of capillary circulation in “On asphyxia” (1841), 224.
68. Snow, “Circulation in the capillary blood-vessels” (1843), 810.
69. Snow was at his most preliminary and least speculative mood in this paper: “I have
nothing to advance respecting the intimate nature of the attractions and repulsions which ac-
company the changes of composition at the capillaries, and which tend to move the blood in
a definite direction. I have carefully avoided such terms as chemical, electrical, and vital, both
in order that I might not be misunderstood, and because I look upon chemical affinity, elec-
tricity, and vitality, rather as expressions which are useful to us in the infancy of science than
as forces which have a separate and defined existence”; Snow, “Circulation in the capillary
blood-vessels” (1843), 813. By contrast, in CMC ten years later Snow would speculate more
fully on the (chemical) nature of these forces and processes.
70. “Circulation in the capillary blood-vessels” (1843), 813. Snow’s proposal to classify a
series of medications as belonging to a single family might at first glance appear to be a stan-
dard move of his time, following in the Linnaean tradition made popular in English medi-
cine by Sydenham and Cullen. What seems to us distinctive is Snow’s use of underlying chem-
ical properties and mechanisms, and not merely similarities in clinical effects, as part of the
rationale for creating the “family.”
71. Porter, Greatest Benefit, 320–21. In the 1840s and 1850s microscopes had relatively poor
resolution, and no chemical stains were available. Snow’s avoidance of microscopy ran counter
to the recommendations of one of his virtual teachers, the physiologist Müller, who particu-
larly emphasized that branch of science; Ibid., 327.
72. Richardson provides a picturesque account of the timid young Snow being largely ig-
nored when he ventured his first comments at the meetings of the Westminster and only very
slowly winning the respect of his elders; L, ix. The records of the meetings as published in the
Lancet and LMG suggest otherwise. Snow seems to have been an active discussant almost from
the beginning of his involvement with the Westminster, at least following his role in the in-
vestigation of the arsenical candles. If anything, he spoke with greater frequency during his
early years in the society than later.
73. For these meeting reports see the notices for “Westminster Medical Society”respectively
in LMG 24 (1838–39): 255–56; Lancet 1 (1842–43): 184; MTG 4 (1852): 22–24; MTG 10 (1855):
167–68; and Lancet 1 (1855): 242–43.
74. “Westminster Medical Society,” Lancet 1 (1838–39): 771–73; “Westminster Medical So-
ciety,” Lancet 2 (1838–39): 200; “Psychotherapeia,” MTG 6 (1853): 331–33; “The Indian plague
and the Black Death,” MTG 7 (1853): 614–15; “Physiological meeting,” MTG 7 (1853): 541–42.
75. Richardson, L, xiii. One would guess that any friend of Snow’s from those days would
probably be active in the Westminster Medical Society. Peter Marshall served as president of
the Medical Society of London in 1869, the year following Richardson’s term in office. On at
least one occasion Snow returned the favor and assisted Marshall in some research. On 14
September 1846 Marshall read a paper on sudden death before the Westminster and ac-
knowledged that Snow assisted him in the autopsy; Lancet 2 (1846): 586.
76. Snow’s health appears to have been indifferent from his student days. Parsons recalled
that Snow periodically suffered from fever and rapid pulse after minor injuries and often ex-
perienced fatigue, even though Snow was able to complete all but the last mile of a fifty-mile,
one-day walk on Easter Monday, 1837; Richardson L, vi. Sometime before 1845 he also de-
veloped symptoms suggestive of incipient pulmonary tuberculosis but “took plenty of fresh
air, and recovered”; L, xiii.
77. The modern view is that Snow suffered from longstanding hypertension that caused
his premature death by stroke; Shephard, JS, 70. Hypertension could result from kidney dis-
ease or could itself be a cause of kidney disease.
78. Richardson, L, x. An exhibit about Snow at the London School of Hygiene and Tropi-
cal Medicine in May 1855 included a poster that stated, “In 1838 he became a visitor to the
Out-patient Department at Charing Cross Hospital”; Clover/Snow Collection, VIII.2. He is
not listed as such in the hospital minute books between 1834 and 1845, although an infor-
mal appointment is a possibility because Charing Cross Hospital was affiliated at that time
with Westminster Hospital, where Snow trained in 1837–1838; search undertaken by Howard
Hague (assistant librarian, Charing Cross Hospital), electronic communications to Brody, 27
March 2002 and 21 June 2002. Although Snow never included an affiliation with Charing
Cross as a by-line in his early articles, he began a late paper as follows: “On commencing, in
the year 1839, to see a considerable amount of practice amongst the poor of London, chiefly
the out-patients of a public hospital, I was very much struck with the great number of cases
of rickets”; “Adulteration of bread as a cause of rickets” (1857), 4.
79. For a contrary but undocumented view that Snow had to complete additional lecture
courses, see Shephard, JS, 38.
80. These questions, mostly from the forensic medicine portion of the exam, were reprinted
in Lancet 1 (1843): 195–96. Julia Walworthy (University of London Library, Paleography
Room) in a letter of 4 August 1989 to Zuck confirmed Snow’s position among the successful
candidates.
81. Richardson, L, xii. The reported minutes of the meetings of the Westminster Medical
Society reflect this change in Snow’s title.
82. Shephard, JS, 39–40. Copy of the original MD examination from the University of Lon-
don Library provided by Zuck, who believes that some of Snow’s research papers in 1843 and
1844 may have been by-products of preparations for the MB and MD examinations.
83. For specific questions, Walworthy to Zuck, 4 August 1989. The name of the portraitist
and the year it was painted remained unknown until Zuck, “Snow, Empson and the Barkers
of Bath.”
84. In 1829 the Lancet advised St. Bartholomew’s prospective students to divide their at-
tention: “Follow the teaching of Lawrence, Stanley and Earle at Bart’s, and go to the Alders-
gate Street School to learn from Clutterbuck in medicine, Cooper in chemistry and pharmacy,
Waller in midwifery, King and Evans for demonstrations in anatomy”; Lancet 1 (1829–30):
47, quoted in Cope, “The private medical schools of London,” 101. Dr. Henry Clutterbuck
(1767–1856), besides being a distinguished lecturer on medicine, was an early president of the
Westminster Medical Society; Story, “Henry Clutterbuck.”
85. “Gossip of the week,” MT 14 (1846): 68. A number of legal issues in medicine related
to paternity and determining whether a woman was pregnant and the date at which she be-
came pregnant. Other legal issues related to determining cause of death, including cases of
poisoning. One of the few publications in which Snow assumed the role of a forensic spe-
cialist was ON, Part 14 (1850), in which he addressed the question of detecting chloroform
administered antemortem in dead bodies. He mentioned several times having consulted with
Dr. Alfred Swaine Taylor, author of a popular textbook of medical jurisprudence and perhaps
the foremost forensic expert of the day, and he described his own investigation of tissues taken
from “a woman who was found dead, under mysterious circumstances, in the Wandsworth
Road” (327), which turned out to be negative for chloroform.
86. Lancet 2 (1846): 345. A similar notice appeared the next year: Lancet 2 (1847): after
362.
87. The first such paper was “Some remarks on alkalescent urine and phosphatic calculi”
(1846). This paper, incidentally, earned Snow praise from another quarter. Golding Bird wrote
a treatise on urinary deposits that went through four editions. In the last he praised Snow’s
experiment on urine alkalinity for its elegance and conclusiveness. Snow’s experiment involved
keeping newly voided urine in an upper vessel at a temperature of 100⬚F and dripping it into
a lower one at about the rate at which it enters the bladder. The upper vessel was emptied
completely and washed every six to eight hours, while the lower one always had a few drops
of the stale urine left in it. The result was that the urine in the lower vessel was always alka-
line, while that in the upper was constantly acid; summation by Zuck. Bird concluded that
“These researches afford a strong argument in favour of the practice of frequently washing
out the bladder, in cases of alkaline urine”; Urinary Deposits, 280. The problem of alkaline
urine, as both Bird and Snow explained, was that it predisposed to the precipitation of phos-
phates and the formation of encrustation and stones.

88. Cope, “Private medical schools of London,” 103–04.
89. Lancet 2 (1848): 376, 412. For Snow’s sense of irony about paying the debts, see Richard-
son, L, xiii.

Cholera Chloroform and The Science of Medicine A L... - (CHAPTER 4 Forging A London Career 1838-1846)

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Chapter 4

Forging a London Career,

I N OCTOBER 1838 John Snow “nailed up his colours” as a surgeon

independent means, a boy of twelve, a painter’s apprentice, and a female servant. In

Finding His Way, 1838–1839

Snow’s Early Publications

Setting His Own Agenda, 1839–1843

Table 4.1. Snow’s published research, 1836–1846

Table 4.1. Snow’s published research, 1836–1846 (Continued)

Atmospheres with 1846d X X X Chemistry, physics,

Snow’s Evolving Scientific Thought

Deeper Into Asphyxia

on their analogy of function with diuretics—the former enhanced excretion through

Seeking an Academic Position

Table 4.2. Prerequisites for a bachelor of medicine (MB) degree

At least 2 years’ attendance at recognized Completed full curriculum, Hunterian

he was prepared.79 He took the examinations given on 23 November 1843. To pass he

Snow; black-and-white reproduction supplied by David Zuck).

Snow in 1846: The Mind Prepared—For What?

Peterson, Medical Profession, 114–15.

variables such as room temperature. Wakley was an advocate of the clinical–pathological

phates and the formation of encrustation and stones.

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